The Diabetic Foot

Dr.Edwin Stephen
The Diabetic Foot

Collection of foot
problems which are
not unique to, but
occur more commonly
in diabetic patients
 Facts

Commonest cause of hospitalization in DM

US 2/3rd of non traumatic amputations

 Facts
Indian figures not known
2004 Surgery Dept Stats
14% admissions – diabetic foot infections ( S2 )
Surgery amputations
DM 87%
major 40
minor 63

Others 13%
major 09
minor 14
Aetiology of the Diabetic Foot
Neuropathy

Reduced response to infection

Ischaemia
 Neuropathy

Up to 50% of type 2 diabetic patients have

significant neuropathy and at-risk feet

International Consensus on the Management and the

Prevention of the Diabetic Foot (2003)
Assessment of Neuropathy
 Neuropathic Foot Changes

Clawing/Retraction of minor
digits
Atrophy of plantar fatty pad
Restricted ROM of joints
Muscle wasting
Warm feet
Changes to joint alignment
Skin anhydrosis
 Charcot Arthropathy

High Index of suspicion

Diabetic
Hot / red / swelling
Trauma - minor / major
Pain + / -
Architectural Disruption
Ulcer + / -
Management of Diabetic Neuropathy

 Look for it!

 Tight glycaemic control
 Painful
 medication
 referral to neurologist
 Intensive podiatry/orthotic input
 Pressure Off-Loading
 Pressure Off-Loading

Diabetic Air Walker

Total Contact Cast
Aetiology of the Diabetic Foot
Neuropathy

Reduced response to infection

Ischaemia
 Diabetic Foot Infection
Polymicrobial - gram (+) cocci, gram (-) bacilli and
anaerobes

Redness and swelling may not be present

Suspect if deterioration in glycaemic control

Unusual foot pain with no fracture etc

 Diabetic Foot Sepsis
Surgical principles
Drain pus urgently / immediately
Xray foot
Assess perfusion
Debride necrotic tissue
Revascularise early if required
MRI useful to assess soft tissues
 Diabetic Foot Sepsis

Severe ischaemia is
present in 5 to 15% of
admitted cases of foot
sepsis
If ischemia present it must be corrected
OR
measures to treat infection/neuropathy
will fail
Aetiology of the Diabetic Foot

Neuropathy

Reduced response to infection

Ischaemia
The concept of small vessel disease is erroneous
and has no place in management of diabetic foot

Distribution similar to atherosclerosis

Foot arteries almost always spared

 Diabetic Vascular Disease
Large vessel disease
common
early age of onset
rapid progression

Microvascular disease
presence in limbs controversial
retinal and renal lesions common
 Assessment of Foot Perfusion
Subjective
palpation of pulses

Objective
Doppler pressures (ankle/brachial index)
toe pressures
NB:ABI unreliable in diabetes/renal failure/ rheumatoid arthritis/leg swelling
 Doppler Studies

Low readings (ABI <0.5)

confirm severe ischaemia

High readings (ABI >0.5)

difficult to interpret if no pulses palpable
Toe Pressures
 Toe Pressures

Better predictors of wound healing

Diabetics
 toe pressure <40mmHg 
 skin perfusion pressure healing very unlikely
40 to 60mmHg 
healing likely
 Management - Medical
↓ Progression of disease

Stop smoking

Rx predisposing factors

Foot care
 Management - Medical
↓ progression of disease
↑ blood flow
Exercises
Drugs
-Antiplatelet :Aspirin / ticlopidine / clopidogrel

-Dipyridamole ( Persantin )

-Pentoxiphylline ( Trental )

-Cilostazol ( Pletoz )
 Management - medical
↓ progression of disease
↑ blood flow
Relief of pain
-NSAIDS: check renal functions

-Opiates: cause constipation

-Epidural analgesia

-Antibiotic

-Drainage abscess
 Management - intervention
Endovascular
Balloon angioplasty +/- Stent

Surgery
Bypass
Anatomical
Aorto-bifemoral
Ileo-femoral
Femoro-popliteal
Extra-anatomical
Axillo-bifemoral
Femoro-femoral
 Case
52 yrs male
Smoking ++
DM X 5 yrs

Rest pain & blackening of right foot x 3 months

B\L lower limb pulses absent

ABI R - 0 , L – 0.2
 Management
Underwent emergency Aorto-bifem bypass and
right trans-tarsal amputation
 Outcome

Post Op ABI left 1.1

Right stump healed well

 Case
55 yrs male
DM x 6 yrs
Smoking many years
Rest pain / nonhealing wound R foot x 4 m
Right lower limb pulses absent
ABI R – 0.24 L – 1.03
 Management
Underwent left fem to right bypass using

8mm ringed PTFE graft

 Outcome

Post-operative recovery uneventful

ABI R 1.07 L – 0.96

Wounds healed well

 Case
60 yrs male
DM x 12yrs
HT x 9 yrs
Heavy smoker
3 months H/O ulceration toes L foot & rest pain
ABI R 0.5 L 0.32
 Management

Underwent left Femoro-popliteal bypass using

reversed LSV
 Outcome

Post op course uneventful

Post-op ABI R – 0.54 L – 0.73

Wound healed within a month

 Case
64 yrs male
DM x 16 yrs
HT x 2yrs
Heavy smoker
Painful nonhealing ulcer left foot
ABI R 0.7 L 0.43
 Management
Underwent balloon angioplasty and stenting of left
common iliac artery
 Management

Followed by
Left Femoro-popliteal bypass using reversed GSV

Patient did well

 Case
69 yrs male
DM + 12 yrs
HT+ / Smoking +
Rest pain left forefoot
Left popleteal and pedal pulses absent
ABI
R – 0.93
L – 0.21
 Management

Underwent fem-anterior tibial bypass using

reversed GSV

Required forefoot amputation

 Management Algorithm for the
Diabetic Foot Lesion
pus/wet gangrene dry gangrene/
in foot present ulceration ±cellulitis/
osteomyelitis

drain
debride

assess perfusion, degree of neuropathy,

mechanical abnormalities
 Management Algorithm for the
Diabetic Foot Lesion
assess perfusion, degree of neuropathy,
mechanical abnormalities

ischaemic foot probably adequate perfusion good perfusion, pulses

ABI <0.5 and/or ABI >0.5 and present, ABI >0.8 and
toe pressure <40mmHg toe pressure 40-60mmHg toe pressure >60mmHg

vascular imaging no vascular intervention no vascular intervention

podiatry/orthotic care podiatry/orthotic care
± local procedure ± local procedure

revascularisation if possible
- angioplasty failure success failure success
- bypass
NB: less likely outcome
THANK YOU !!